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What matters most?...

Contributor: Marina Kotsani

Origin/affiliation: Geriatrician (France, Greece)

Since the moment I stumbled upon the 4Ms model for Creating Age-Friendly Health Systems(1), I have been seduced by the fourth «mousquetaire», the brilliant forth “M”. Of course, Mobility, Mentation, Medication are very important aspects for consideration when caring for older people, but what Matters seemed to be a revelation for me in the way of looking at Geriatric Medicine. The aspect of an individualized approach to the older patient has of course been omnipresent all throughout our training and clinical practice in Geriatrics, but what Matters most is more than an individualized approach to the person by the physician, more than what the physician thinks is the most relevant goal: it’s about the alignment of the older person’s specific health outcome goals and care preferences, with their personal values, their life philosophy. It’s with consideration, care and excitement that I try tackle “what matters most”, going through the person’s life history, their beliefs, their present aspirations, their projections to future.

However, it has been a short time that I started thinking of “what matters” in another point of view. I have been a big fun of Massive Online Open Courses for a while and I recently started taking a course on “Finding Purpose and Meaning In Life: Living for What Matters Most”, by Prof Vic Strecher(2). It is dealing with subjects such as living a “big” life, in harmony with one’s values, finding one’s purpose, which is actually what makes us keep going on. Reflecting on the suggestion that what gets us out of bed in the morning, keeps us active, resilient and eventually alive is our purpose in life, one wonders what happens if there is no answer to the question “what matters” to someone…

So “what matters” can be a compass that guides our life and health choices, but can also be the driving force, the meaning one gives in their lives, the reason to overcome crisis and to get going or … not. My mind went back at a moment in my life as a nursing home physician some days ago when I was trying to explain, first to myself, and then to the family of an old lady her “failure to thrive”. I was trying to prepare them for the end that was approaching. Certainly, she suffered from numerous comorbidities, an extreme frailty and a severe degree of loss of autonomy. But are they enough to explain why this lady is spending her remaining energy in resisting to the care we were providing to her, in refusing to eat and in splitting out her medicines? Is there any antidepressant drug that can fix this? What about people who were managing quite well until the moment that their spouse or even their dog died and had no longer nobody to take care of?

Maybe in a few years’ time we will be able to explain all these in scientific terms. Maybe we will discover deficient brain regions (there is indeed some relevant research!) or excessive cytokines production or too low hormone levels to explain this absence of reason to get going. For the time being even the art of medicine is not wide enough to enclose this existential mystery, which leaves me full of awe and humbleness.

At the end of our appointment, I whispered to the old lady’s daughter “focus on taking care of your father now”: stepping out of my office, he seemed too frail to afford losing the reason that kept him going on.


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